Clinical Practice Guidelines for the Management of Adult Gliomas: Astrocytomas and Oligodendrogliomas

Brain tumours are uncommon tumours but they have a devastating effect on patients’ lives and the lives of their caregivers. Although malignant brain tumours make up only two percent of all cancers they result in the fourth highest loss of potential years of life. On average a patient with a malignant brain tumour loses 12 years of potential life; the highest average loss of life from any type of cancer.

Because of this, brain tumours cause the highest economic burden on Australian cancer patients’ households, with an average cost estimated to be more than five times higher than for breast or prostate cancer patients. These guidelines have been developed to provide information on malignant adult brain tumours (specifically gliomas) to medical practitioners and interested community members. The aim is to direct attention to improve the level of practice and understanding in a health area that causes considerable community anxiety. Brain tumours also contribute heavily through costs of hospital, home and community management to the budget of the Australian health care system. They impose the highest economic burden on carers of any cancer, as well as significant emotional and physical challenges.

Guidelines for adult gliomas are needed because of the considerable variation in clinical practice. A patterns-of-care study in Victoria has recently documented that only 74% of patients were referred for radiotherapy and only 54% saw a medical oncologist. Radiotherapy offers a major survival benefit but only 68% of patients with glioblastoma multiforme received radiotherapy. It is unlikely that one third of patients were too unfit for treatment. There is no reason to believe that the situation is different in other Australian States.

It is a common misconception that there is not much evidence to support glioma management. This is far from the case; high-level randomised data exist from many trials of treatment and for many supportive interventions. Controversies exist and are best viewed in the light of systematically assembled evidence. Thus the necessary conditions exist for the development of guidelines; a high ommunity burden, evidence of variation in practice and good evidence on optimum patient management.

These guidelines are for the management of adult gliomas including low- and high-grade gliomas (anaplastic astrocytoma, glioblastoma multiforme and oligodendroglioma). They encompass all aspects of patient management, not just treatment. A general approach to patients is suggested because it is recognised that a diagnosis of brain tumour can have profound implications. Clinical presentation, diagnostic work up and imaging are reviewed. Treatment is discussed separately for low-grade gliomas, high-grade gliomas and oligodendrogliomas.

Clinical trials are the major route for the development of new treatments, yet in the Victorian study, only 5% of patients participated in clinical trials. We present a chapter on clinical trials as a resource to encourage greater participation in trials.

A great many cancer patients seek further hope in complementary, alternative and unproven treatments. We provide some guidance on the range of treatments offered and some tools for the critical appraisal of complementary, alternative and unproven treatments.

We also present guidance about continuing care including psycho-social support, the management of symptoms, rehabilitation, follow-up and palliative care. Management is often complex because of the interaction of multiple medical problems and behavioural and psychosocial issues. We examine in detail the management of headaches, steroids and anti convulsants and the current legal requirements about driving.

Adult gliomas (astrocytomas and oligodendrogliomas): a guide for patients, their families and carers

This guideline has been developed to provide information about malignant brain tumours (specifically gliomas) in adults, for people with cancer and their families and carers.

This booklet has been designed as a summary of current Australian guidelines for doctors: the Clinical practice guidelines for the management of adult gliomas: astrocytomas and oligodendrogliomas, published in 2009 by the Australian Cancer Network/Cancer Council Australia.

Over the past decade there has been considerable improvement in outcomes for patients with glioma. There has been a growing interest in research to increase survival and improve patients’ experience.

There is now high-quality evidence from many clinical trials of brain tumour treatments and supportive care. These guidelines bring together a wide range of evidence to give an overall picture of the current state of the art in brain tumour management.

This guideline covers all aspects of patient care, not just treatment targeting the tumour itself. It includes information about symptoms, diagnosis and brain scans, and separate sections on treatment for low-grade astrocytoma, high-grade astrocytoma and oligodendrogliomas.

The guideline also provides information on topics that are of particular interest for some patients, including:

participation in clinical trials

what is currently known about the effectiveness of complementary, alternative and unproven treatments